Frozen Shoulder

[21st century Physio]

Hi All,

Im a University Student. Just have a few questions about effective treatment for adhesive capsulitis.

I'm basically just looking for some Physio's who have experience treating this condition to write what treatment techniques worked best for them. Most of the reading I have done suggests that a corticosteroid injection combined with vigorous shoulder joint mobilisation is most effective?

Also what exactly is hydrodilation and when would you advise this form of treatment to a patient with frozen shoulder?

Cheers,

Simon

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[estherderu]

Sorry Ginger and physio210,

Maybe I was a little too fast in this case...

What I meant to say was that focussing treatment on the humeroscapular joint has not been very successful in the past decades. We have been trying all sorts of things on this poor joint and to little avail.

The name is probably part of the problem ... it nothing more than a very general description of ROM problems in this particular joint.

As Ginger states focus on the cervical spine. Assessing the whole spine and thorax is an essential part of the assessment as well. Good luck in your search.

Esther

[physio210]

"So the answer might be that there is no effective physiotherapy treatment for this problem."

absolutely not........

Ever so briefly, just don't be focussed on the shoulder, the answer and the best treatment lies in the cervical spine. Not manipulation, not massage, but mobilisation with a view to restoring a non protected state of normal freedom of movement , specifically, though not limited to , C456, ipsil. Continuous Mobilisation applied there to facet joints will restore this non protected state, leading progressively to a less irritated series of nerve roots , associated with normal sensations ( or lack therof ) to the shoulder complex..

but is it applicable when the problem in the structur of the shoulder joints itself not from the nerve??
do you have article that support your idea??

[alophysio]

Hi Physio210,

There are many people who like to have people do research for them. I understand you are only trying to get ideas.

However, this is primarily a clinical site. Therefore, what we see in practice, adapted from science, are not always researched yet in proper trials.

Have you done your searches on Adhesive Capsulitis? Perhaps you could share with us what your literature search has shown so far. What have your search terms been? What have the main treatments that have been looked at been? Who seem to be the leading publishing authors on the subject?

I do not mean to discourage you but i do want to encourage you to share your findings.

If you haven't got the above information, do you think asking a forum for the answers is the best way to start researching the topic - i am assuming you are a physiotherapist or a student...

...just my thoughts

[physio210]

hi alophysio
in the literature they mostly showed that end range mobilization is better than low grade in term of increasing the mobility, also posterior glide better than anterior, physical exercises and passive stretch have good effect.

i want to do questionnaire on this, so i want the idea from the therapist who have exeperience and workson the OPD
t am student
thank you

[Men At Work]

hey guys i've recently started my practice wherein i have a frozen shoulder case which is responding at a slow pace with passive range coming in flexion ,abduction and ext rotation coming in 3 weeks.now the problem lies is the still lower range in external rotation with elbow in 90 deg flxn at the side of body.and also the movement pattern for external rotation starts with arm going into slight abduction first.im giving grade 2 glides with strengthning of shoulder girdle till 90 degrees of flexion.please help in improvement for the range and strength.thank you.also the active range is coming till 80 degrees in flexion and 70in abduction.any guidance will be appreciated.the pt had a fracture greater tuberosity humerus 3 months back.

[SPPAWA]

For those who have dealt with/ or had Frozen shoulders have you also found there has been some notable stressful event in the patients/ your life within 3 months of onset?

Cheers,

SPPAWA

[alophysio]

Hi MenAtWork,

If they have a frozen shoulder, it will be a frozen shoulder. If they have cervical referral, it will get better with C/S treatment, if they have a fracture of the greater tuberosity, you will need to treat it accordingly...but the important question is..."What is the diagnosis?".

Hi SPPAWA,

Usually the most notable thing in histories to me are between about 45-65y.o. and a recent, sometime innocuous shoulder injury - could have been bumper or jarred etc. stress in life is not comping up strong in my memory (and i do ask...)

[SPPAWA]

Please review the following paper as it pertains to psychological aspects which appear to correlate with frozen shoulder. Personality in frozen shoulder -- Fleming et al. 35 (5): 456 -- Annals of the Rheumatic Diseases

Frozen shoulder in the majority of what I have read is usually referred to as an idiopathic adhesive capsulitis. If they were more commonly traumatic the etiology would be known and the condition likely titled more appropriately. Personally, I feel this condition is largely brain based and my clinical encounters with it support the distinct personality characteristics in those that I have seen with the condition, anxiety most notably. It is always tempting to blame an onset on clipping the shoulder in a doorway but I think if we step back and look at how many times we "bump" ourselves in any given day it would seem that the insult is disproportionate to the level of injury. Trauma as I'm sure you will agree tends to be more limited in the initial stages. Frozen shoulders come on slowly and unfortunately do not follow typical healing times for soft tissue injury as we see in shoulder injury. As I'm sure you'll agree diagnosis is paramount and I have also quite often seen impingement misdiagnosed as "frozen shoulder."

Hope you enjoy the read,

SPPAWA

[alophysio]

Hi SPPAWA,

Thanks for that...a free copy of the article can be found here...http://www.ncbi.nlm.nih.gov/pmc/arti...00036-0069.pdf

It is hardly a resounding scientific piece of evidence i must say. i had trouble finding articles that cited it and went further with the idea....although i must admit it was only a cursory look on Pubmed and Google Scholar to see if it had been quoted/cited anywhere else...

As for personality issues, how does it explain the red capsule and fibrosis seen on arthroscopy?

BTW, that paper is from 1976...

Cheers!

[ginger]

Pain is by it's very nature , distressing. This is particularly so when occurring for , apparently , no reason. Added to which the sufferer of the so called "frozen shoulder" may hear of other sufferer's tales of woe, their various unsuccessfull attempts at dealing with it and the variety of opinions on it's cause, treatment and natural history. Little wonder that those with this diagnosis ( I should include here those with "impingement" diagnoses as well) have cause to be worried, anxious and more. It would seem to be a somewhat natural feature of any pain related problem that seems to confuse professionals whose poorly established opinions , ,in many cases , adds fuel to the anxiety fire.
I find commonly that once patients have had the problem explained to them , it's cause, it's likely sequence during appropriate treatment and an establishment of therapeutic attention, anxiety virtually ceases.

[SPPAWA]

Hello Alo,

Agreed, that last paper as not a real winner but I thought I would do a little better to support my view that an emotional predisposition may be an important factor that is often overlooked when a patient presents with a frozen shoulder. I hope you will find these interesting. If you can’t source them free just contact me privately and I can send you a copy if you’d like.


NEUROTICISM, EXTRAVERSION, ANXIETY AND TYPE A BEHAVIOUR AS MEDIATORS OF NECK, SHOULDER AND LOWER BACK PAIN IN FEMALE HOSPITAL STAFF 1996
Neck-shoulder pain and depressive symptoms: a coho... [Eur J Pain. 2010] - PubMed result


influence of comorbidity on self-assessment instrument scores of patients with idiopathic adhesive capsulitis 2002
http://www.ejbjs.org/cgi/content/abstract/84/7/1167

Neck–shoulder pain and depressive symptoms: A cohort study with a 7-year follow-up 2010
Elsevier

As for the pathohistological changes seen in the capsule, my theory would be that increase drive from uninhibited alpha motor neurons to glenohumeral capsular muscles may promote a metabolic deficiency and thus the associated fibrotic changes. I feel this increased drive could be produced secondary to a lack of decreased cortical inhibition. In this case cortical fatigue or possibly a TIA would allow a “release phenomenon” of more primitive brainstem postural reflexes drive tone to the capsular pattern seen in the pathology. If this were the case, increased output of rubrospinal projections could possibly promote the inappropriate alpha motor neuron tone to the end organ, in this case the capsular muscles of the shoulder. Granted, a trivial trauma which also offsets proper proprioceptive feedback to coordinative centers and potentially compromises reflexogenic fuel delivery could also promote such change. In the cases I have seen the trauma does not follow a typical natural history. In fact, as I’m sure you’ll agree, it usually worsens and shows an impressive recalcitrance to treatment. To me this is different to trivial traumas where TENS, IFT, soft tissue cryotherapy and manipulation at least provide some relief. Interesting stuff none the less. Let me know if you can’t get those articles and would like a read.

Keep well,

SPPAWA